9/16/22, 5:11 PM View/Print Submitted Form
File Number (For Office Use Only)
GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS
PASSPORT APPLICATION FORM
Please read the Passport Instruction Booklet carefully before filling the form. Fill this form
in CAPITAL LETTERS using
blue/black ink ball point pen only. Furnishing of incorrect information/
suppression of information would lead to rejection of the
application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your original
documents at the time of submission of the form.
Service Required
Application Reference Number 22-1010682267
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet JUMBO
Applicant Details
Applicant's Name BEBEJAAN SHAIK
Date of Birth (DD/MM/YYYY) 21/08/1960
Validity Required NA
Place of Birth (Village/Town/City) VIJAYAWADA
District KRISHNA
State/UT ANDHRA PRADESH
Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender FEMALE of Illiterate Applicant and Minors
who
Marital Status SEPARATED cannot sign.
Citizenship of India by BIRTH
Employment Type HOME MAKER
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification 7TH PASS OR LESS
Are you eligible for Non-ECR category? Y
Aadhaar Number 652562835259
Family Details
Father's Name MEERA SAHEB SHAIK
Present Residential Address Details
32-15-106-2,DASARILINGHAYYA STREET,B BLOCK,G 5,
Address
VIJAYAWADA, VIJAYAWADA CITY, ANDHRA PRADESH
PIN 520010
Police Station MACHAVARAM
Mobile/Tel No. 7386527228
E-mail SKAMEENABEGUM18@GMAIL.COM
Permanent Residential Address
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9/16/22, 5:11 PM View/Print Submitted Form
32-15-106-2,DASARILINGHAYYA STREET,B BLOCK,G 5,
Address
VIJAYAWADA, VIJAYAWADA CITY, ANDHRA PRADESH
PIN 520010
Police Station MACHAVARAM
Mobile/Tel No. 7386527228
Emergency Contact Details
Name and Address AMEENA BEGUM
Mobile/Tel No. 9963512011
Other Details
Payment Details
Mode of Payment UPI
Date 16/09/2022
Receipt/Reference No. CPACAWHKL0
Amount Received (Rs.) 1800.00 (ONE THOUSAND EIGHT HUNDRED ONLY)
Enclosures
1.Aadhaar Card/E-Aadhaar
2.Aadhaar Card (Address Proof)
Self Declaration
I owe allegiance to the sovereignty, unity & integrity of India, and have not voluntarily acquired citizenship or travel document of any
other country. I have not lost, surrendered or been deprived of the citizenship of India. I have not contravened any of the conditions
relating to the possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am not suppressing
any material information in this regard. I further affirm that the enclosures and documentary proof submitted in support of my
application for an Indian passport are authentic and solely pertain to me and I am fully responsible for the accuracy of the same. I
am liable to be penalized or prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to
furnish any false information or to suppress any material information with a view to obtaining passport or travel document.
I have read and understood the contents of the above and by submitting this form certify that all the information submitted by me in
the form is bonafide.
Place VIJAYAWADA Signature/Left Hand Thumb Impression of
Applicant
(If applicant is minor, either parent
Date 15/09/2022 to sign)
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